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General NPI Number Information
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NPI Number | 1497173363
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Entity Type | Organization
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Legal Business Name | ADVANCED WELLNESS PHYSICAL THERAPY, PC
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Dates
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Enumeration Date | 03/28/2014
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Last Update Date | 03/28/2020
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Provider Practice Location Address
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Address Line | 34799 FAIRPORT WAY
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City | YUCAIPA
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State | CA
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Zip | 92399-6819
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Country | US
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Telephone | 909-553-3434
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Fax |
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Provider Business Mailing Address
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Address Line | 34799 FAIRPORT WAY
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City | YUCAIPA
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State | CA
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Zip | 92399-6819
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Country | US
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Telephone | 909-262-0928
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | MS. LEANNE CHAVEZ
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Credential | P.T.
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Telephone | 909-553-3434
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT15801
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License Number State | CA
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